Committed to quality, constrained by context: A qualitative exploration of midwives’ perspectives on the quality of maternity services in rural Ugandan hospitals

Introduction: Despite substantial progress over the last decade, maternal mortality rates remain high in many low- and middle-income countries, and women continue to die from largely preventable pregnancy-related and birth-related causes. Research shows that improving the quality of maternity care could be one key means of preventing some of these deaths. However, many health systems continue to face challenges in delivering high-quality care, including in Uganda. As quality of care is influenced by how key healthcare practitioners perceive, interpret, and deliver care, understanding their perspectives is essential. This study explored how midwives understand and reason about quality of care in their facilities in rural Uganda. Methods: This study used a qualitative approach and six focus group discussions involving 25 midwives from two health facilities in rural Uganda. Discussions explored participants’ perceptions of quality maternity care and factors influencing the provision of care. Data were analysed using qualitative content analysis. Results: Results show that midwives perceived quality care during birth as something that they all aspired to achieve, while simultaneously experiencing obstacles they felt were beyond their control. This is reflected in the overarching theme ‘Feeling limited power over the quality of care provided in their hospital’. This theme was supported by three subthemes. These subthemes capture how midwives see quality care during birth as holistic, encompassing care before pregnancy, during childbirth, and in the postnatal period, while feeling powerless due to systemic and organisational constraints. Participants also identified supportive leadership and opportunities for further education as central factors that would enhance their capacity to provide high-quality care. Conclusions: These findings suggest that midwives understand quality of maternity care as a holistic process shaped by interactions between individual providers and the organisational and wider health-system contexts in which they work. Participants emphasised the importance of strengthening organisational and managerial conditions, alongside continued professional development, to support the provision of high-quality maternity care in rural Uganda.